肺源性与肺外源性急性呼吸窘迫综合征的再思考

Reconsideration of Pulmonary and Extra-pulmonary Acute Respiratory Distress Syndrome

急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)是由一系列疾病损伤导致的急性呼吸衰竭,重症患者具有较高的病死率。根据危险因素的不同,ARDS可分为肺源性ARDS和肺外源性ARDS两种亚型,前者由于损伤直接作用于肺泡上皮细胞,造成肺泡膜破坏,影响气血交换;而后者通过全身性因素导致血管内皮损伤,肺血管通透性增加、肺间质渗出,进而出现肺泡塌陷、水肿,呼吸衰竭。各种肺内外危险因素在重症ARDS患者中往往同时存在,影像和呼吸力学等临床特征也未能很好区分肺源性/肺外源性ARDS,生物标志物的诊断效应还需验证,甚至病死率在肺源性/肺外源性ARDS患者中也并无明显差异。本文对肺源性ARDS和肺外源性ARDS的危险因素、临床特征、病死率进行比较,并针对ARDS的发病机制、临床表现及治疗与预后需关注之处进行梳理,为临床医生更加全面了解ARDS的发病机制、规范系统地启动ARDS的精准化评估与治疗提供借鉴,从而降低ARDS患者的病死率。

Acute respiratory distress syndrome(ARDS)is a kind of respiratory failure caused by a series of etiologies,with high mortality in critically ill patients.According to different insults,there are pulmonary ARDS and extra-pulmonary ARDS.Pulmonary ARDS damages epithelial cells and alveolar membrane directly,while extra-pulmonary ARDS damages alveolar endothelial cells and causes increased permeability,interstitial edema,and collapsed alveoli.Pulmonary and extra-pulmonary insults usually co-exist in critically ill ARDS patients so that we couldn't differentiate them according to etiology,clinical characteristics,biomarkers or mortality.In this article,the differences in risk factors,clinical features,and mortality of pulmonary ARDS and extra-pulmonary ARDS are compared,and we comb the pathogenesis,clinical manifestations,treatment and prognosis of ARDS which are extremely important.It enables intensive care physicians to have a more comprehensive understanding of the pathogenesis of ARDS,and can standardize and systematically initiate the precise assessment and treatment of ARDS,thereby reducing the mortality rate of ARDS patients.